In my last post, I reviewed a paper that showed how disorganized we are at responsibly prescribing and providing instructions for use of opioid pain medications. Today, I’ll look at a paper that attempts to provide a bit more concrete guidance on what to do.

This study was performed at Dartmouth, and consisted of a questionnaire sent to a group of patients who had undergone an inpatient general surgical procedure during a 6-month period. These were not trauma procedures, but included gastric bypass, sleeve gastrectomy, lap or open ventral hernia repair, laparoscopic fundoplication, hepatectomy, lap or open pancreatectomy, and lap, open, or robotic colectomy. The authors specifically looked at opioid use before discharge, length of stay and complications, and opioid prescriptions and refills.

After excluding patients who had preop opioid use or abuse, and those who developed postop complications, there were 234 study patients. Here are the factoids:

• Overall, 85% patients were given opioid prescriptions, and only 38% of the medication prescribed was taken
• Patients discharged on postop day 1 had different requirements from those who were discharged later, and were studied separately
• 88% of patients discharged on day 1 had their opioid needs satisfied by 15 pills
• For patients discharged after day 1, there was a very strong correlation with home needs and the amount of opioid required on the before discharge
• 41% of patients took no pills the day prior to discharge, 33% took 1 to 3, and 26% took more than 4
• Proper disposal of unused meds was extremely variable

Based on this information, the authors calculated that 85% of patients’ home opioid use would be met by using the following guideline:

• If no pills were used the day prior to discharge, none were prescribed
• If 1-3 were taken, 15 were prescribed
• If 4 or more were taken, 30 were prescribed

The authors estimated that, if these guidelines had been followed in the patients reviewed, the number of pills prescribed would have decreased by about 40%.

Bottom line: This is an interesting attempt to answer our questions about opioid use after discharge. Of course, there are limitations in extrapolating this to the trauma population. The pain patterns in patients with fractures, chest trauma, or multiple injuries are very different than those with abdominal general surgical procedures,  especially those performed with a laparoscope  or robot. But it does demonstrate some key concepts:

• It should be possible to systematize discharge prescribing in a significant number of patients
• We need to provide guidelines and expectations to our patients to help them minimize their use of opioids after discharge
• We also need to make sure that our patients know what to do if they run out of medication
• These guidelines must include safe disposal instructions for unused meds so they can’t be diverted for inappropriate use

I’m looking forward to more papers that help quantify these concepts. In the meantime, I guess I’ll hit the drawing board and start sketching out an interim guideline to tide me over until that happens!